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General NPI Number Information
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NPI Number | 1801807375
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Entity Type | Organization
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Legal Business Name | WISCONSIN EATING DISORDER SPECIALISTS SC
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Dates
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Enumeration Date | 08/10/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 34700 VALLEY RD
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City | OCONOMOWOC
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State | WI
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Zip | 53066-4500
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Country | US
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Telephone | 262-646-1387
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Fax | 262-646-7067
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Provider Business Mailing Address
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Address Line | 3630 N HICKORY LN
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City | OCONOMOWOC
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State | WI
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Zip | 53066-4532
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Country | US
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Telephone | 262-646-1387
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Fax | 262-646-7067
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Authorized Official
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Title or Position | OWNER
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Name | THEODORE WELTZIN
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Credential | MD
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Telephone | 262-646-4411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number |
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License Number State |
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